Sticks and Stones and Broken Bones

The first time I saw a vertebra in medical school was not in anatomy lab. It was on a Thursday afternoon on the playground at Rolling Bends, a low-income housing community in West Atlanta. The smooth, white bony processes poked through the woodchips alongside broken glass and cigarette butts, almost, but not quite, unnoticeable.

To be fair, I do not know if the bone came from a human body or not. But it could have. Fifteen feet from where we stood speaking with Miss Faith, the kind and fiery vice president of the residents’ council, a pile of weather-worn teddy bears marked the spot where two weeks earlier a twenty-year old resident crumpled to the ground. He was the latest victim of the latest bullet. He was not the first; he will not be the last. “It happens,” Miss Faith explained. “I got a text at work, maybe six in the evening. It said, ‘There’s a dead body by your place.’ And you know what? It was still there at 3 a.m. the next morning.” The group of students shifted, uneasy. Some had questions. Most stayed silent. “That’s what it’s like here. The police came, sure. But what can they do? That’s just how it is.”

As first-year medical students, many of us struggled to explain what exactly we were doing at Rolling Bends. We were part of the school’s first-ever course in “community learning and social medicine,” an experience designed to introduce students to the complexity of Atlanta and confront the stark disparities that influence health. The goals of the course were intentionally opaque, leaving room for flux and innovation. Among the students, the trepidation was palpable. We began by visiting, listening, trying to learn.

Before long, vans from the local schools drove through and deposited the community’s children before pulling away. They ran from the parking lot down the path towards their mothers, braids flailing, arms outstretched. Miss Faith, who has raised her own two children and is now caring for two school-aged grandsons, continued. “I want to move, of course. I want somewhere quiet. This is war here, it really is. This is Vietnam.”

Part II

Fall has come and gone, and by now we have all slid our scalpels through skin. We have peeled back muscles and traced tendons to bone. We have spent long evenings in the basement anatomy lab, our fingers exploring the edges of vertebrae, serpentine arteries, the slick sheen of fascia. We learned the sound of a bone saw splitting skulls. Those who were initially haunted by the frozen faces under white sheets became almost immune to the sight.

Meanwhile, we spent the days learning in the lecture hall upstairs. Our minds began to fill spin with hazy knowledge of the things that attack us: bacteria and viruses, fungi and parasites. And we slowly took stock of our natural defenses: T-cells coordinate the immune response, B-cells provide ammunition. The complement system triggers multiple cascading pathways, all culminating in pathogen destruction. Natural killer cells offer a swift solution for intracellular infections and nascent tumors. Though we dreaded the immune system’s complexity, we were awestruck by its elegance.

But in the harsh reality of nature, every adaptation is a double-edged sword. Once we’d covered the elements of the immune system, we began to unravel the conundrum of autoimmunity. These diseases appeared in each system we studied: the lungs, the joints, the skin, the gut. Though the myriad illnesses manifest differently, they are united by an underlying concept: The natural defenses that help protect us from the outside world often cause more harm than help. In some cases, we develop antibodies to particular parts of our own tissues or organs. In others, we attack the benign bacteria that we depend on for health. Often, we don’t understand what went wrong. Scientists propose that they are caused by a mixture of our genes, our environment, and our exposures. Biology meets circumstance, and patients suffer. Doctors scratch their heads, perplexed.

The origin of these diseases is largely unknown. Scientists believe that they are the result of an evolutionary mismatch between the infectious threats our species have evolved to combat and the relative hygiene of the Western world. Our bodies, initially armed and primed to protect, do not encounter the anticipated invaders. Amidst the confusion, we turn inwards.

Part III

Outside the lecture halls, the world spun steadily on. In West Atlanta, the violence persisted. Despite all odds, Miss Faith continued to welcome us at Rolling Bends. We were eager, curious and confused. The community was in pain, but it was hard to pin down its nature. At school, we had learned to take a patient history: “Can you describe the pain? How long have you felt it? Has anything made it better or worse?” and used the answers to establish diagnoses and decide on treatments.

One Wednesday afternoon, a couple of students sat with a group of residents in the community center to discuss their concerns. We hoped to gain insight into the causes of their pain. They cited failing school systems and lack of opportunities for teenagers and children. They spoke about the growing problem of high school dropouts, with many young men trading homework assignments for ammunition. When more vocal residents offered their observations, others nodded their heads in stoic affirmation. A few young children squirmed in their mothers’ laps.

Suddenly, bullets outside split the air like cracking bones. The gunshots were separate at first: a tibia breaking. The residents did not move, but looked at us as if to say, “See?” This was routine. And then the gunshots came faster and closer, circling around the community center. It sounded of shattering femurs and spines, like a bone saw splitting skulls. The routine had ended; this was different. Inside the center, we all hit the floor, crawled down the hallway into the bathrooms. The mothers clutched their children as we squatted together in the bowels of the building. A three-year old girl’s eyes stretched wide and she asked: “Why are people shooting again?” She knew well the rhythm of gunfire, though she could not write her name.

Our neighborhoods are turning inwards. They are using their defenses to attack their own. Ammunition, anti-bodies. This pain is profound and insidious and chronic.

Autoimmune conditions are notoriously difficult to treat. How do you convince the body to reduce its response without making it vulnerable to the threats that are real? It is a delicate balance. We suppress our immune systems, but run the risk of infection. Physicians try their treatments with varying results. Often these patients are passed between specialists, moving from one to the next when attempts fail. Recently, targeted therapies have met more success. There is often relief, but we have not found a cure.

Community violence is no simpler. How do we convince a community that its greatest danger is, in fact, the tools that would seem to protect it? And how can we prevent a condition that has so many causes, and which we do not fully understand?

Part V

When the gunfire grew loud enough at Rolling Bends, the community had no choice. They called for back-up. SWAT teams arrived, and soon the land was covered with more armed men who patrolled the area for the shooters. They scoured the buildings for the culprits, aiming to remove them, to lock them up alone. But this disease has no guilty microbe, and it has no Patient Zero. It is not just a virus whose carriers must be quarantined until they are somehow, miraculously healed.

Once the SWAT teams controlled the chaos, we drove away from Rolling Bends and have not been back since. The reasons were multiple and often opaque. We were not safe, administrators told us. The community needed to heal. They needed more protection. We could not be close to the source of the violence in case we got caught in the crossfire. The pain was too profound, and we did not have the tools to treat it.

I imagine there are more bones beneath the woodchips at Rolling Bends. I believe they are piling up across the country, bone-white fragments emerging from the ground around schools, behind corner stores and apartment buildings. As the spines of the victims collapse, those of the policy-makers crumble. Bullets pierce organs and lodge deep within. In operating rooms, scalpels slice into bodies, gloved fingers set broken bones in broken bodies. Lives shatter into fragments that do not fit back together. We are desperate to heal the victims. This is too little, too late.

Originally from Atlanta, Georgia, Amara has bounced around the country a bit before landing back in her hometown for medical school. She enjoys hiking, traveling, exploring the city and thinking about fun things like human evolution. Email her if you’d like to talk!

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in-Training is the agora of the medical student community, the intellectual center for news, commentary, and the free expression of the medical student voice. We publish articles about humanism in medicine, patient stories, medical education, the medical school experience, health policy, medical ethics, art and literature in medicine, and much more.